IvyPlus Exchange Scholar Program Application Purpose The IvyPlus Exchange Scholar Program enables a graduate student enrolled in a doctoral program in one of the participating institutions to study at one of the other participating graduate schools for a limited period of time at no additional tuition cost, in order to take advantage of educational opportunities not available on the student’s home campus. Duration of a participating student’s enrollment at a host school may be for one or more terms (which may be recorded in quarters or semesters, depending on the institution), with a maximum exchange enrollment of one year. (In the case of a student accompanying a dissertation adviser who has joined the host school, more than a year’s enrollment as an Exchange Scholar may be permitted if all parties are in agreement.) Any extensions to an approved exchange enrollment require a separate application form. The academic experience, including courses taken and/or research conducted with particular faculty at the host institution, is reported to the student’s home institution to be recorded on the academic record maintained by the home institution. It may also be recorded by the host institution. Participating students may be required to confirm the transfer of credit with their home institution. Eligibility and Application Process Terms and conditions for the IvyPlus Exchange Scholar Program are found at the end of this application. The graduate schools of the institutions listed at the end of the application are participants in the IvyPlus Exchange Scholar Program. If a student is currently enrolled in a doctoral program at one of these institutions and wishes to study for a term or academic year at another, the student should read the relevant terms and conditions and complete the application as instructed. All approvals from the home and host institutions must be obtained at least two months before the enrollment date at the host institution. Most participating institutions can enroll exchange students only at the start of a term. Please refer to a host institution’s academic calendar for relevant dates. Please be aware that a host institution may charge an application fee or fees for services that are not covered by tuition, such as health and hospitalization charges. It is a student’s responsibility to meet such charges. International students on a F-1 or J-1 visa may remain on the visa sponsorship of their home institutions and maintain their immigration status. They must contact their home institution’s international student office before accepting any on-campus or off-campus employment. Effective Dates The IvyPlus Exchange Scholar Program was renewed in September 2018 for a five-year period. However, the participating institutions may modify the program at any time, and individual institutions may withdraw from the program at any time. 1 Please do not use the Mac built-in Preview application to fill out this form. Rather, download Adobe to complete the form. Parts of the Application Each part of the application must be completed. • Parts A through C are completed by the student applying for the exchange. • Part D is completed by the administrative contact at the home institution. • Parts E and F are completed by the administrative contact at the host institution. The roster of administrative contacts is found at the end of the application, along with terms and conditions. A. Student Information. Please print or type all information. Legal Name (last, first and middle) Preferred Name (if applicable Name of Home Institution Student ID number at Home Institution Date of Birth Legal Sex (for government reporting) Email address at Home Institution Country of Citizenship Birthplace (City, State, Country) Visa Status (international students only, F-1 or J-1) For students in the U.S. on a student visa, the home institution will continue to issue certificate of eligibility (I-20 or IAP-66). In your home institution program: Doctoral Degree Program (e.g., History, Chemistry) Term of initial registration or enrollment (e.g., Fall 2017) Expected completion date of degree (e.g., May 2023) 2 Quarter(s)/Term(s)/Semester(s) you propose to spend at the host institution (e.g., Fall 2020, Spring 2021). Please check with the host school exchange administrator first if you are proposing to visit during a time that includes a summer term. Not all institutions can accommodate the exchange during a summer term. Have you participated in the Ivy Plus Exchange Scholars Program before? Yes No If yes, when and where? Name of Proposed Host Institution Department or Program at Host Institution Subfield, subject or area of concentration Adviser at Host Institution (if applicable) Address to which bills or other information should be sent: Address 1 Address 2 City/State/Zip Telephone Please describe your proposed plan of study during the exchange and indicate why it is essential to your degree program. (Attach another page if necessary.) If you plan to enroll in courses at the host institution, please provide the following information on the courses you wish to take. Enter information exactly as it appears in the host institution’s course offerings. Note that some departments at a host institution may not allow exchange students to enroll in their courses. 3 Attach email correspondence showing approval by the instructor(s) of the course(s) you wish to take. Correspondence should be from the university email account of the instructor(s) and explicitly state the course number, title and term, as well as approval. Term Course No Course Title Credit Basis Instructor Name Funds for support for the requested period of study are available as follows: Source Type Tuition Living Stipend (e.g., Home Inst, External) (e.g. Fellowship, Research asst., Loans) ($ amount) ($ amount) Ordinarily students will not receive any financial support from the host institution. Will any financial support come, or be paid through, the host institution, for example as an assistantship in research or teaching fellowship? YES NO If yes, and if you are an international student on a visa, you must contact the visa office at your home institution, as well as the visa office at the host institution, prior to your arrival. Do you require support from the Accessibility or Disability Services Office at the host institution? YES NO Note: If yes, contact the relevant office at your home institution and ask that that office make contact with the relevant office at the host institution. The administrative contacts for the exchange at both the home and host institutions can help with referrals to the appropriate offices. Sign the following statement: I hereby petition to participate in the IvyPlus Exchange Scholar Program and to undertake the course of study outlined above. I agree to abide by the terms and conditions of this program as well as the regulations and procedures of both institutions. I understand that violation of any of the regulations can result in my suspension from the program. I authorize the transfer of record of courses and/or research conducted with a particular faculty member at the host institution to my home institution and understand that I may need to request this transfer separately. Student Signature Date 4 B. Approvals. Obtain the signed approval of the following individuals at your home institution. Emailed approvals may be accepted by the administrative contact only if they are from the university email account of the signer and explicitly state the exchange dates and host institution, as well as approval of participation as described in the application. 1. Academic Adviser Name Title Signature Date 2. Director of Graduate Studies or Department Chair Name Title Signature Date C. Submission. Submit this form to your home institution administrative contact for review, approval, and processing. Administrative contacts are listed at the end of the application. Only the administrative contact may forward applications to the host institution. Administrative Contact for Exchange Name Title Signature Date D. Home Institution Administrative Contact. The home institution administrative contact should review Parts A-C of this application. If approved, please make sure your signature appears in Part C and then forward this application to the IvyPlus Exchange Scholar Program administrative contact at the host institution the student plans to visit. E. Host Institution Administrative Contact. Please obtain the approval of the following persons for the student’s proposed course of study at your institution. (You sign in part E-3.) Emailed approvals may be accepted if they are from the university email account of the signer and explicitly state the exchange dates and host institution, as well as approval of participation as described in the application. 5 1. Academic Adviser (if relevant) Name Title Signature Date 2. Director of Graduate Studies or Department Chair Name Title Signature Date 3. Administrative Contact for Exchange Name Title Signature Date F. A complete and signed application should be held at the host institution for administrative processing. Copies of the complete and signed application with any attachments should be returned to the student and to the administrative contact at the student’s home institution. 6 PARTICIPATING INSTITUTIONS AND ADMINISTRATIVE CONTACTS University of California at Berkeley All Ph.D. programs Contact: Maritsi Perez Degrees Office, 318 Sproul Hall, #5900 Berkeley, CA 94720-5900 Phone: 510.642.7330 Fax: 510.643.1524 Email: [email protected] or [email protected] Academic calendar: http://registrar.berkeley.edu/CalendarDisp.aspx?terms=current Brown University All Ph.D. programs Contact: Thomas Lewis Associate Dean of Academic Affairs Brown University Box 1867 Providence, RI 02912 Phone: 401.863.1181 Fax: 401.863.3471 Email: [email protected] Academic calendar: http://www.brown.edu/Administration/Registrar/calendar.html University of Chicago All Ph.D. programs Contact: GRAD Exchange UChicagoGRAD 970 E.